Inconsistency of Prescription Labels Risks Medication Errors

Medication errors cause thousands of deaths in the United States every year. A recent study by the University of Waterloo and the Canadian National Institute for the Blind determined that many of these errors are caused by illegible labeling.

Many factors can affect the legibility of a drug label from a pharmacy. Fonts that are too small, overly crowded instructions, and inconsistencies in the location of information on prescription drug labels can all cause confusion for patients. Elderly adults, who are already susceptible to medication errors, have the most trouble with these details.

According to the study, very few labels actually followed the professionally recommended guidelines for legibility of prescription labels recommended by the following:

  • The US Pharmacopeia
  • The American Society for Consultant Pharmacists
  • The National Patient Safety Agency in the UK
  • The American Foundation for the Blind
  • The Canadian National Institute for the Blind
  • The Royal National Institute of Blind People in the UK
  • The American Council of the Blind

The following discrepancies affected the legibility of the labels in the study:

  • Only 44% of the medication instructions used 12-point font size, the minimum accepted print size for optimal legibility.
  • Not a single drug or patient name on labels in the study met the minimum 12-point font standard.
  • 95% of the labels were judged to have overly crowded information, making it difficult to read important information, especially for those with diminished eyesight.
  • Just 51% of the labels used left alignment, which is recommended for legibility.
  • The instructions were given in complete sentences, making it difficult for patients to interpret.
  • There was a lack of consistency of the location of different types of information.
  • Every label in the study fell short of legibility recommendations in some way.

Improving Prescription Legibility

In order to study the legibility of labels currently used by pharmacies, researchers in the Waterloo study had 45 Canadian pharmacies in Kitchener, Waterloo, and Cambridge print a sample prescription label with the patient’s name, drug name, and instructions. They then compared the labels to each other and to label printing recommendations from pharmaceutical and health organizations and non-governmental organizations for ideal readability.

The researchers determined not only that recommendations were being ignored, but also that there were very few requirements for legibility and readability being handed down to individual pharmacies. In order to rectify this problem, researchers have proposed new guidelines and regulations for label size, font size and color, sentence alignment, and highlighting.

The researchers next plan to create a prototype for a uniform label and test it on both patients and pharmacists to try to improve legibility standards. “We expect that addressing these factors together will improve the accessibility of prescription labels. We need to move from a pharmacy-centered labeling standard, to a patient-centered one,” said Carlos H. Rojas-Fernandez, Professor at Waterloo’s School of Pharmacy and researcher on this study. In the meantime, patients need to be aware of this lack of clarity and make sure to read prescription bottles especially carefully.